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Hip Resurfacing

Policy Number: 7.01.80 Last Review: 7/2018

Origination: 10/2006 Next Review: 7/2019

Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for hip

resurfacing when it is determined to be medically necessary because the criteria

shown below are met.

When Policy Topic is covered Metal-on-metal total hip resurfacing with a device system approved by the U.S.

Food and Drug Administration (FDA) may be considered medically necessary as

an alternative to total hip replacement when the patient:

Is a candidate for total hip replacement; AND

Is likely to outlive a traditional prosthesis; AND

Does not have a contraindication for total hip resurfacing (See Considerations).

Partial hip resurfacing with an FDA-approved device may be considered medically necessary in patients with osteonecrosis of the femoral head who have one or

more contraindications for metal-on-metal implants and meet the following

criteria:

The patient is a candidate for total hip replacement; AND

Is likely to outlive a traditional prosthesis; AND

The patient has known or suspected metal sensitivity or concern about potential

effects of metal ions; AND There is no more than 50% involvement of the femoral head; AND

There is minimal change in acetabular cartilage or articular cartilage space

identified on radiography.

When Policy Topic is not covered All other types and applications of hip resurfacing are considered investigational.

Considerations The U.S. Food and Drug Administration (FDA) lists several contraindications for

total hip resurfacing. These contraindications include (not a complete listing) the following:

Bone stock inadequate to support the device due to:

Hip Resurfacing 7.01.80

o severe osteopenia or a family history of severe osteoporosis or severe

osteopenia

o osteonecrosis or avascular necrosis with more than 50% involvement of the femoral head.

o multiple cysts of the femoral head (more than 1 cm)

Skeletal immaturity

Vascular insufficiency, muscular atrophy, or neuromuscular disease severe enough to compromise implant stability or postoperative recovery

Known moderate to severe renal insufficiency

Severely overweight

Known or suspected metal sensitivity Immunosuppressed or receiving high doses of corticosteroids

Females of child bearing age due to unknown effects on the fetus of metal ion

release

A 2012 FDA advisory panel of experts identified young males with larger femoral

heads as the best candidates for hip resurfacing systems. (1) The FDA advises that

a metal-on-metal hip implant should be selected only after determining that the

benefit-risk profile of using a metal-on-metal hip implant outweighs that of using

an alternative hip system. Factors to consider include the patient’s age, sex, weight, diagnosis, and activity level. Patients should be informed about the

benefits and risks of metal-on-metal hip implants, including the risk that the hip

implant may need to be replaced. Patient expectations and the potential

complications of surgery with a metal-on-metal hip implant should be discussed.

Total hip resurfacing should be performed by surgeons who are adequately trained

and experienced in the specific techniques and devices used.

Description of Procedure or Service Populations Interventions Comparators Outcomes

Individuals: With indication for hip

replacement who would outlive a

traditional prosthesis and no contraindication for hip resurfacing

Interventions of interest are: Metal-on-metal

total hip

resurfacing device

Comparators of interest are: Any traditional

total hip

arthroplasty device

Relevant outcomes include: Symptoms Change in disease

status Functional outcomes Health status measures Quality of life Treatment-related

morbidity

Individuals: With indication for

hip replacement who would outlive a traditional prosthesis and no contraindication for hip resurfacing

Interventions of interest are: Partial hip

resurfacing device

Comparators of interest are: Any traditional

total hip arthroplasty device

Relevant outcomes include: Symptoms Change in disease

status Functional outcomes Health status measures Quality of life

Treatment-related morbidity


Hip resurfacing is an alternative to total hip arthroplasty (THA; also known as hip

replacement) for patients with advanced arthritis of the hip. Total hip resurfacing

(THR) describes the placement of a shell that covers the femoral head together with implantation of an acetabular cup in patients with painful hip joints. Partial

hip resurfacing is considered a treatment option for avascular necrosis with

collapse of the femoral head. Available prostheses are metal-on-metal devices.

For individuals who have an indication for hip replacement who would outlive a

traditional prosthesis and have no contraindication for hip resurfacing who receive

a metal-on-metal total hip resurfacing device or a partial hip resurfacing device,

the evidence includes 2 randomized controlled trials, numerous large observational studies, large registry studies, and systematic reviews. Relevant outcomes are

symptoms, change in disease status, functional outcomes, health status measures,

quality of life, and treatment-related morbidity. The efficacy of THR performed

with current techniques is similar to that for THA over the short-to-medium term, and THR may permit easier conversion to a THA for younger patients expected to

outlive their prosthesis. Based on potential ease of revision of THR compared with

THA, current evidence supports conclusions that hip resurfacing presents a

reasonable alternative for active patients who are considered too young for THA—

when performed by surgeons experienced in the technique. The literature on adverse events (eg, metallosis, pseudotumor formation, implant failure) is

evolving as longer follow-up becomes available. Due to the uncertain risk with

metal-on-metal implants, the risk-benefit ratio needs to be considered carefully on

an individual basis. In addition, emerging evidence has suggested an increased risk of failure in women, possibly due to smaller implant size. Therefore, these

factors should also be considered in the overall patient evaluation for THR, and

patients should make an informed choice with their treating physicians. The

evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.


traditional prosthesis and have no contraindication for hip resurfacing who receive,

the evidence includes 2 randomized controlled trials, numerous large observational studies, large registry studies, and systematic reviews. Relevant outcomes are

symptoms, change in disease status, functional outcomes, health status measures,

quality of life, and treatment-related morbidity. Therefore, these factors should

also be considered in the overall patient evaluation for THR, and patients should make an informed choice with their treating physicians. The evidence is sufficient

to determine that the technology results in a meaningful improvement in the net

health outcome.

Background

Hip resurfacing is an alternative to total hip arthroplasty (THA; also known as total

hip replacement) for patients with advanced arthritis of the hip. Total hip

resurfacing (THR) describes the placement of a shell that covers the femoral head together with implantation of an acetabular cup. Partial hip resurfacing is

considered a treatment option for avascular necrosis with collapse of the femoral

head.


THR has been investigated in patients with osteoarthritis, rheumatoid arthritis, and

advanced avascular necrosis as an alternative to THA, particularly in young active patients who would potentially outlive a total hip prosthesis. Therefore, hip

resurfacing could be viewed as a time-buying procedure to delay the need for a

THA. Proposed advantages of THR compared with THA include preservation of the

femoral neck and femoral canal, thus facilitating revision or conversion to a THR, if required. In addition, the resurfaced head is more similar in size to the normal

femoral head, thus increasing the stability and decreasing the risk of dislocation

compared with THA.

THR has undergone various evolutions, with modifications in prosthetic design and

composition and implantation techniques. For example, similar to total hip

prostheses, the acetabular components of THR have been composed of

polyethylene. However, over time it became apparent that device failure was frequently related to the inflammatory osteolytic reaction to polyethylene debris

wear particles. Metal acetabular components have since been designed to improve

implant longevity. Sensitivity to wear particles from metal-on-metal chromium and

cobalt implant components are of increasing concern.

Regulatory Status

In 2006, the Birmingham Hip Resurfacing system (Smith & Nephew Orthopaedics),

a metal-on-metal resurfacing system, was approved by the U.S. Food and Drug

Administration through the premarket approval (PMA) process for use in patients requiring primary hip resurfacing arthroplasty for noninflammatory or

inflammatory arthritis. This decision was primarily based on a series of 2385

patients who received this device by a single surgeon in England. A number of

postapproval conditions were required, including the following items:

Study longer term safety and effectiveness through 10-year follow-up of the

initial 350 patients in the patient cohort that was part of the PMA.

Study the “learning curve” and the longer term safety and effectiveness of the

Birmingham Hip Resurfacing system in the United States by studying 350 patients at up to 8 sites where clinical and radiographic data will be assessed

annually through 5 years and at 10 years. Also, determine cobalt and chromium

serum concentration and renal function in these patients at 1, 4, and 10 years.

Implement a training program to provide clinical updates to investigators.

Two additional metal-on-metal hip resurfacing systems have been approved: in

2007, the Cormet™ Hip Resurfacing System (Corin) and, in 2009, the Conserve®

Plus Total Hip Resurfacing System (MicroPort Orthopedics). Both implants were approved for skeletally mature patients with either: noninflammatory degenerative

arthritis (eg, osteoarthritis and avascular necrosis); or inflammatory arthritis (eg,

rheumatoid arthritis). (Note: patients with the latter arthritis might be individuals

who, due to younger age or increased activity level, may not be suitable for traditional THA because it would increase the possibility of requiring ipsilateral hip

joint revision.)


Various devices have been cleared for marketing by the Food and Drug

Administration through the 510(k) process for partial hip (femoral) resurfacing.

Some surgeons may be using a femoral resurfacing component together with an acetabular cup (total arthroplasty component) as an off-label application.

Rationale This evidence review was created in August 2001 and has been updated regularly with searches of the MEDLINE database. The most recent literature update was

performed through February 5, 2018.

Evidence reviews assess the clinical evidence to determine whether the use of a

technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to functionincluding benefits and

harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome

measures are necessary to ascertain whether a condition improves or worsens;

and whether the magnitude of that change is clinically significant. The net health

outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net

health outcome of a technology, 2 domains are examined: the relevance and the

quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an

effective and appropriate alternative at a comparable intensity. For some

conditions, the alternative will be supportive care or surveillance. The quality and

credibility of the evidence depend on study design and conduct, minimizing bias

and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; RCTs controlled trials are rarely large

enough or long enough to capture less common adverse events and long-term

effects. Other types of studies can be used for these purposes and to assess

generalizability to broader clinical populations and settings of clinical practice.

Total Hip Resurfacing

This review was informed by a TEC Assessment (2007) that evaluated studies of

patients with advanced degenerative joint disease of the hip who received a total hip resurfacing (THR) device and who reported data on short- and long-term

clinical outcomes, including benefits and harms, as an alternative to total hip

replacement (total hip arthroplasty [THA]).1 The Assessment included an RCT2 and

12 uncontrolled series, along with U.S. Food and Drug Administration (FDA)

premarket application submission data,3 and information from the Australian Orthopedic Association National Joint Replacement Registry.4 The aggregate data

suggested that THR-treated patients who do not require a revision have

substantial symptomatic reductions in pain and improvements in hip function over

presurgical status.

The TEC Assessment also evaluated the patient safety and efficacy data

considered for FDA submission of the Birmingham device from the McMinn cohort,3


which are supported by unpublished data on 3374 hips implanted by 140 surgeons

and published reports on more than 3800 hips treated by multiple surgeons

(worldwide cohort). With regard to long-term safety, literature summaries provided to FDA demonstrated increased serum and urinary concentrations of

metal ions postoperatively in patients with THA, particularly after metal-on-metal

(MoM) procedures, but data showed no conclusive evidence of significant

detrimental effects. TEC concluded that use of FDA-approved MoM THR devices meets the TEC criteria as an alternative to THA in patients who are candidates for

THA and who are likely to outlive a traditional prosthesis.

Patient Selection Criteria In 2011, the American Academy of Orthopaedic Surgeons provided a technology

overview of modern MoM hip implants.5 The National Joint Registry for England

and Wales reported that hip resurfacing patients in all age groups, except men

younger than 55 years of age, were at an increased revision risk compared with cemented THA using an unspecified bearing surface. The Australian registry

reported that hip resurfacing patients 65 years of age or older had the highest

revision risk. Head size and risk of revision for THR were inversely related to each

other. Patients who received the smallest femoral head components (eg, women)

had the greatest risk of revision. The implant size was associated with poorer outcomes when the sex by implant size interaction was analyzed. This analysis

supports the view that THR is most effective in men who are too young to receive

THA. A 2013 FDA advisory panel of experts also identified young men with larger

femoral heads as the best candidates for hip resurfacing systems.6

Nunley et al (2009) reviewed 207 publications, most of which had little or no

description of the patient population, small sample sizes, poor study designs,

limited control of bias, and inadequate statistical analysis.7 The literature showed no clear consensus on the upper age limit for male patients, but the most

commonly used criterion was age (<65 years). Nine articles suggested that female

patients should be cautiously evaluated before performing hip resurfacing,

especially if they are postmenopausal or have decreased bone mineral density.

Some data reviewed was from the Australian Joint Replacement Registry, in which women 65 or older were observed to have a revision rate of 11% at 4 years. This

was compared with men younger than 55 years of age who had a revision rate of

less than 2%. Both of these cohorts (older women and younger men) have

revision rates of 2% after THA. The Nunley review also indicated that obesity, defined as body mass index (BMI) greater than 35 kg/m2, can be viewed as a

relative contraindication to THR, but not THA. Femoral head cysts, head-neck

junction abnormalities, and poor bone density may also be considered risk factors

for implant failure. At the time of this review, the literature on metal sensitivity and the presence of aseptic lymphocytic vasculitis-associated lesions was evolving,

and the potential for transplacental transfer of metal ions was a concern for young

female patients with the potential to become pregnant in the future. Reviewers

concluded that the best candidates for hip resurfacing were men younger than age 65 with osteoarthritis and relatively normal bony morphology.


Efficacy of THR vs THA

THR vs Standard THA

Systematic Reviews

A systematic review by Marker et al (2009) compared outcomes from THR with

those from THA in studies with short- to mid-term follow-up.8 The 7 comparative studies that assessed “return to sports and activity” revealed either similar

outcomes for the 2 procedures or advantages for the THR group. Three additional

studies assessed gait, and another study was identified that assessed postural

balance; all 4 studies revealed similar or better outcomes for THR than THA.

Jiang et al (2011) published a systematic review comparing MoM THR with THA in

patients younger than 65 years.9 Included were 4 RCTs (total N=968 patients).

Hip function scores were similar between groups, although the resurfacing group showed higher activity levels.

Quesada et al (2008) published a qualitative systematic review that compared the

advantages and disadvantages of THR with THA.10 Advantages were reported to

include possible bone conservation on the femoral side, lower dislocation rates, more range of motion, more normal gait pattern, increased activity levels,

increased ease of insertion with proximal femoral deformities or retained

hardware, and straightforward revision. Possible disadvantages of resurfacing were

reported to be increased difficulty to perform the procedure, increased acetabular bone stock loss, femoral neck fractures, and the effects of metal ions. Although

prospective controlled studies with long-term follow-up are needed for conclusive

evaluation of these issues, the literature reviewed by these investigators

suggested an increased risk of femoral neck fractures in postmenopausal women and small-boned men.

Clinical Studies

An RCT by Haddad et al (2015) was intended to evaluate clinical and functional

outcomes of THR using the Birmingham system and to compare it with that of a cementless hip arthroplasty in patients under the age of 55 years.11 Between 1999

and 2002, 80 patients were enrolled in the trial; however, only 24 consented to

random allocation to treatment (11 to THR, 13 to THA). Eighteen patients refused

THR and chose to undergo THA with a 32-mm bearing; 38 patients selected THR. The mean follow-up for all patients was about 12 years (range, 10-14 years).

Patients were assessed clinically and radiologically at 1 year, 5 years, and 10

years. Outcome measures included Oxford Hip Score, Harris Hip Score (HHS),

University of California Los Angeles (UCLA) and University College Hospital functional scores. No differences were observed between the 2 groups in the

Oxford or Harris hip scores or in the quality of life scores. At 10 years, more

patients who underwent THR were able to run than those who underwent THA

(53% vs 19%; p=0.1), were able to participate in sport activities (86% vs 52%; p=0.09), and were able to perform heavy manual labor (20% vs 13%; p=0.19),

all respectively. Patients who had undergone THR exhibited significantly higher

functional status scores than those who received a cementless THA at 10 years.


Blood levels of cobalt and chromium ions were reported for 72 patients (49 THA,

23 THR); at 5- and 10-year follow-ups, all remained below a 7 parts per billion

threshold for toxicity.

Mont et al (2007) compared gait analysis in 15 patients after successful THR with

15 patients who had a successful THA using a small femoral head, and with 10

patients who had osteoarthritis and 30 age- and sex-matched controls from a normative database.12 Walking speed (1.3 m/s) was faster in the THR group than

in the THA group (1.0 m/s) or osteoarthritis group (1.0 m/s). Measurement of

abductor and extension moments found that the gait of patients following THR was

closer to normal than the gait of patients who had undergone THA.

THR vs Large-Head THA

Two controlled trials randomized patients to THR or THA with a large diameter

MoM implant.13,14 Lavigne et al (2010) tested the hypothesis that the observed improvement in activity with THR is due to patient selection bias or to the larger

femoral head with THR.13 To test this hypothesis, 48 patients were randomized to

THR or large-head THA. The patients and evaluators at the gait laboratory were

kept blinded to the type of arthroplasty until 1 year after surgery. There were no

differences between groups for most of the measures at 3, 6, and 12 months postsurgery. Specifically, similar results were observed for normal and fast

walking, postural evaluations, Timed Up & Go test, hop test, and hip flexor and

abductor strength ratio. The THR group performed better during the Functional

Reach Test, and the THA group completed the step test 3 seconds faster than the THR group. The Western Ontario and McMaster Universities Osteoarthritis Index,

36-Item Short-Form Health Survey (SF-36), Merle D’Aubigne, and UCLA Activity

Scores were similar in both groups.

In the other trial, Garbuz et al (2010) randomized 107 patients to THR or large-

head MoM THA.14 There were no differences in the Western Ontario and McMaster

Universities Osteoarthritis Index or SF-36 scores for the 73 patients who had been

followed for at least 1 year. However, for the subset of patients who had been

tested for serum levels of cobalt and chromium, cobalt was 10-fold higher and chromium was 2.6-fold higher in the large-head MoM THA group than in the THR

group. This was a 46-fold increase from baseline in serum cobalt and a 10-fold

increase from baseline in serum chromium for the large diameter head THA group,

possibly related to particulate wear at the head-neck junction. Both studies supported the hypothesis that the improved activity observed in THR patients is

due to the larger diameter components used in resurfacing.

Revision Rates

Systematic Reviews

A systematic review by Jiang et al (2011) compared revision rates for MoM THR

with those for THA from 4 randomized or controlled trials with 968 patients younger than 65 years.9 Analysis found increased rates of revision with THR at 1-

to 10-year follow-ups; the relative risk was 2.60. However, this analysis did not

evaluate the effect of age, bearing head size, or sex, which have been shown to


have a significant effect on revision rates in registry data.5 As previously

discussed, the National Joint Registry for England and Wales reported that hip

resurfacing patients in all age groups, except males younger than 55 years of age, were at an increased revision risk compared with cemented THA using an

unspecified bearing surface. Analysis of data from the Australian registry found

that head size and risk of revision for THR were inversely related to each other.

Patients receiving the smallest femoral head components (eg, women) had the greatest risk of revision. The implant size was associated with poorer outcomes

when sex by implant size interaction was analyzed.

Cohort Studies A study by Azam et al (2016) evaluated long-term (minimum, 10-year follow-up)

survivorship and functional outcomes of Birmingham THR performed by a single

surgeon between 1999 and 2004 in patients with hip osteoarthritis.15 In this

retrospective cohort study, revision surgery was considered the end point of survivorship. Prosthetic survival analysis was performed with the Kaplan-Meier

method. A total of 222 patients (244 hips) included 153 men and 69 women. At a

mean follow-up of 12 years, 94% of implants were intact. In males, implant

survival was 95% while in females, it was 90%. Failure was seen in 14 patients

(16 hips), which included 7 (10%) female and 7 (5%) male patients. Femoral components failed due to aseptic loosening and varus collapse in 8 patients after a

mean of 9.6 years. Metal allergy was reported in 3 patients (5 hips), all of whom

were female; two of the latter had bilateral resurfacing. Other complications

included femoral neck stress fractures in 2 patients and acetabular component loosening in 1 patient. The failure rate was higher in patients who received a THR

femoral component size of 46 mm or less (10/16 hips revised).

A prospective cohort study by Daniel et al (2014) reported on long-term implant survival results from a single surgeon series of Birmingham THR.16 The earliest

1000 consecutive THR implants comprised 335 hips (288 women) and 665 hips

(598 men) of all ages and diagnoses without exclusions, who were prospectively

followed with mailed questionnaires; the first 402 hips (350 patients) also had

clinical and radiologic review. The mean follow-up was nearly 14 years (range, 12-15 years). In total, 59 patients (68 hips) died 0.7 to 12.6 years postsurgery from

unrelated causes. Thirty-eight revisions were required at 0.1 to 14 years (median,

9 years) following operation. These included 17 femoral failures (2%) and 7 each

due to infections, soft-tissue reactions, and other causes. With revision for any reason as the end point, Kaplan-Meier survival analysis showed 97% (95%

confidence interval [CI], 97% to 9%) and 96% (95% CI, 95% to 96%) survival

rates at 10 and 15 years, respectively. Radiologic assessment showed 11 (4%)

femoral and 13 (4%) acetabular radiolucencies, and 1 (0.3%) radiologic femoral failure. Men appeared to have better implant survival rates (98%; 95% CI, 97% to

99%) at 15 years than women (92%; 95% CI, 90% to 93%); women younger

than 60 years had the poorest implant survival rate (90%; 95% CI, 88% to 93%).

Patients younger than 50 years with osteoarthritis had the best results (99% survival at 15 years; 95% CI, 99% to 100%), with no failures in men in this

group.


In a series of 554 patients, Murray et al (2012) found that the 10-year implant

survival rate in women was 74% compared with 95% in male hips, and the 10-

year revision rate for pseudotumor was 7% compared with 1.7% for male hips.17 Patient-reported outcomes on the Oxford Hip Score and UCLA Activity Score were

also higher in men.

In a series by Matharu et al (2013), which evaluated 447 patients younger than 50 years of age, implant survival in women was 96.1% at 10 years and 91.2% at 14

years, compared with 100% for men at both 10 and 14 years.18 Female sex

(p=0.047) and decreasing femoral head size (p=0.044) were significantly

associated with an increased risk of revision.

An analysis by Pailhe et al (2014) assessed 162 patients 65 years of age or older

found 10-year implant survival rates of 98.9% in men and 91.9% in women.19

Implant survival was negatively associated with increasing age (p=0.014) and decreasing femoral head size (p=0.024), with a nonsignificant trend for a negative

association with female sex (p=0.079).

Amstutz et al (2010) reported on 12-year follow-up (range, 10.8-12.9 years) from

the first 100 hip resurfacings at their institution.20 Kaplan-Meier implant survival was 93.9% at 5 years and 88.5% at 10 years. Subgrouping by femoral component

size showed a 10-year survival rate of 95.6% for a component size of greater than

46 mm, 83.8% for component sizes of 44 or 46 mm, and 78.9% for a component

size of 42 mm or less. Multivariate analysis showed that low BMI, small femoral component size, and large defects in the femoral head were risk factors for failure.

High scores for activity level were not associated with an increased risk of revision.

Other studies have suggested a high learning curve for THR related to the increased difficulty in accessing the acetabular compartment. For example, in the

study by Kim et al (2008), most failures were related to early acetabular

loosening.21

A report by Nunley et al (2010) suggested that, for experienced hip surgeons, the learning curve for avoiding early complications (eg, early femoral fracture) is 25 or

fewer cases, but the learning curve for achieving the desired component

positioning is 75 to 100 or more cases.22

Gross et al (2012) reported that in 373 hips from the first multicenter FDA-

regulated trial on hip resurfacing with the Cormet prosthesis, the learning curve

was at least 200 cases, with survival at 11 years of 93% for the first 100 cases,

93% for the second 100 cases, and 98% for the last 73 cases.23

THR to THA Conversion

Systematic Reviews A systematic review by Marker et al (2009) identified 2 studies that compared the

outcomes of conversion of failed THR with THA for primary THA.8 One was a the

report by McGrath et al (2009), which compared outcomes of 39 patients whose


resurfacing was converted to THA with a group of primary THA patients matched

by sex, age, BMI, and preoperative HHS; all procedures had been performed by

the same surgeon.24 Perioperative measures were similar except for the mean operating time, which was 19 minutes longer for the revision group. At an average

45 months of follow-up, the mean HHS were similar for both groups (92 for

conversion to THA vs 94 for primary THA).

Clinical Studies

Another study, by Ball et al (2007), compared outcomes in 20 patients (from a

group of 844 primary THRs performed between 1997 and 2005) requiring

conversion surgery for failed THR (5 femoral neck fractures, 16 with femoral component loosening) with outcomes in 58 patients of similar age (64 hips from

patients <65 years) treated using a primary THA by the same surgeon during the

same period.25 The acetabular component was retained in 18 hips (and revised in

3 because the matching femoral head was not available at the time of surgery). The study found no significant differences in operative time between conversion

(178 minutes; range, 140-255 minutes) and primary THA (169 minutes; range,

110-265 minutes), or in complication rates between groups (14% vs 9%,

respectively). At 1- to 9-year follow-up (average, 46 months for the THR-THA

revision group vs 57 months for the primary THA group), outcomes as measured by the UCLA, SF-12, and HHS were similar (eg, HHS, 92 for the revision group vs

90 for the primary THA control group). Although this small study suggested that a

resurfaced femoral component might be converted to THA without additional

complication, larger comparative studies assessing THR-THA and THA-THA revisions would be needed.

De Steiger et al (2010) reported on outcomes for revised THR from the Australian

Joint Replacement Registry.26 A total of 437 revisions were reported (of 12,093 primary THR, 4%) between 1999 and 2008. After excluding 39 revisions for

infection, the major reason for revision of primary THR was fracture of the femoral neck (43%), followed by loosening/lysis (32%), metal sensitivity (7%), and pain

(6%). A femoral-only revision, which converts the joint to a conventional THR, was

performed in 247 (62%) of the 397 revisions undertaken for reasons other than

infection. At 3 years, the rate of re-revised THR-THA was 7%, compared with

2.8% of primary conventional THA. Reasons for re-revision included loosening/lysis (n=6), infection (n=4), dislocation of prosthesis (n=1), and

fracture (n=2). At 5 years, femoral-only re-revision (7%) was similar to re-

revision of both the acetabular and femoral components (5%), but the rate of

acetabular-only re-revision was 20%. A more relevant outcome for this evidence review, one that the investigators did not assess, would be a comparison of the re-

revision rates for THR-THA with THA-THA revisions.

Adverse Events The study by Reito et al (2014) was intended to evaluate 10-year survivorship of

Birmingham THR; to investigate whole blood metal ion levels; to assess the

prevalence of adverse events to metal debris; and to assess the relation between

blood metal ion levels plus symptoms of adverse events and metal debris among

patients who underwent THR at a single institution.27 Between 2001 and 2004,


219 patients received 261 THR implants. All patients with intact devices underwent

systematic screening comprising clinical examination, whole blood cobalt and

chromium measurements, and targeted cross-sectional imaging; any implant revision was the key study end point. At 10-year follow-up, device survival for the

entire cohort was 91%, with revision required in 10 (6%) men and 13 (20%)

women. The prevalence of adverse events to metal debris was 7% in male and 9%

in female patients; it was associated with revision in 3 (2%) men and 8 (9%) women. Pseudotumors were observed most commonly in symptomatic patients

who had elevated metal ion levels (63%) than in asymptomatic patients who had

elevated metal ion levels (42%) and symptomatic patients who had nonelevated

metal ions (11%).

Williams et al (2011) assessed the prevalence of pseudotumor formation by

ultrasound in asymptomatic patients with MoM THA (n=31) or MoM THR (n=21).28

Results were compared with 24 asymptomatic patients with a metal-on-polyethylene THA. At a minimum of 2 years after surgery (mean, not reported), 10

(32%) patients in the MoM THA group had a solid (n=7) or cystic mass (n=3), 5

(25%) patients in the THR group had a solid (n=3) or cystic mass (n=2), and 1

(4%) patient in the metal-on-polyethylene THA group had a cystic mass. Isolated

fluid collection was similar across the 3 groups (10%, 5%, and 8%, respectively). Serum chromium and cobalt ion levels in patients with MoM prostheses ranged

from 2 to 720 times the upper limit of normal. There was no correlation between

the serum metal ion levels and the size of pseudotumor abnormality and no

significant difference in serum metal ion levels in patients with pseudotumor formation than in patients without pseudotumors in this small study. The high

percentage of patients diagnosed with a pseudotumor in this study is due in part

to a definition of pseudotumor that included cystic without solid mass.

Kwon et al (2011) determined the prevalence of asymptomatic pseudotumors after

MoM THR in 201 hips.29 All patients who had surgery at least 3 years previously

(n=228) were invited to participate. The 158 patients who agreed to participate

underwent evaluation by ultrasound, followed by biopsy and magnetic resonance

imaging if a tumor was identified on ultrasound. Mean follow-up was 61 months (range, 36-88 months). Pseudotumors that contained both cystic and solid

components were identified in 4.4% of patients (6 female, 1 male) and 6.5% of

resurfaced hips. Histologic examination of the pseudotumors showed extensive

necrosis of connective tissue and scattered aggregates of metal particles within necrotic macrophages in extracellular tissue. The pseudotumors were associated

with significantly higher cobalt and chromium levels from serum and hip aspirate.

A retrospective study by Steffen et al (2008) of 610 consecutive hip resurfacings (120 with >5-year follow-up) attributed failure to metal debris in 0.5% of THRs.30

However, after examining histologic samples taken at the time of revision, Ollivere

et al (2009) concluded that the rate of metallosis-related revision in their series of

463 consecutive patients was 3% at 5 years.31 All patients in this series had been recruited into the local arthroplasty follow-up program at the time of the primary

surgery; 437 (94%) returned for clinical and radiologic follow-up at a mean follow-

up of 43 months (range, 6-90 months). Case notes, radiographs, and magnetic


resonance imaging scans were available for the 13 revisions (2.8%, 12 patients).

Histologic findings were available for 12 cases and were re-reviewed by a

histopathologist with experience in metal wear and debris. In 7 cases, the histologic findings were consistent with a response to metal wear debris.

Survivorship analysis gave an overall survival rate of 95.8% at 5 years, with an

end point survival of 96.9% at 5 years for metallosis requiring revision. The

relative risk for female sex in the metallosis group was 4.94. Also associated with metallosis were a smaller femoral component, greater abduction angle, and a

higher BMI.

Mont et al (2007) described the results of FDA-regulated investigational device exemption prospective, multicenter trial of the Conserve Plus hip resurfacing

system in 2007.32 The investigators identified a number of risk factors for

complications after the first 292 procedures; they included the presence of cysts,

poor bone quality, leaving reamed bone uncovered, minimizing the size of the femoral component to conserve acetabular bone, and malpositioning of the

acetabular shell. Modification of inclusion criteria and surgical technique in the

next 906 patients (1016 hips) resulted in a decreased rate of femoral neck fracture

(from 7% to <1%). A trend was reported suggesting reduction in other types of

complications (eg, nerve palsy was reduced from 4.1% to 2.2%, loosening of the acetabular cup from 3.4% to 1.9%). No differences between the 2 cohorts were

observed in the HHS (93 vs 93) or the SF-12 (eg, Physical Component Summary

score, 50 vs 50).

Section Summary: Total Hip Resurfacing

The evidence on THR includes 2 RCTs, numerous large observational studies, large

registry studies, and systematic reviews. The efficacy of THR performed with

current techniques is similar to that for THA over the short-to-medium term, and THR may permit easier conversion to a THA for younger patients expected to

outlive their prosthesis. Based on potential ease of revision of THR compared with

THA, current evidence supports conclusions that hip resurfacing presents a

reasonable alternative for active patients who are considered too young for THA.

The literature on adverse events (eg, metallosis, pseudotumor formation, implant failure) is evolving as longer follow-up becomes available.

Partial Hip Resurfacing

A search of the literature on resurfacing for osteonecrosis identified a number of articles, including a review by Grecula (2005) and a study by Stulberg et al

(2009).33,34 Both discussed comparisons of hemiresurfacing to THR, referencing a

single comparative study by Beaule et al (2004).35 This literature showed that total

resurfacing/replacement provided more consistent and better initial pain relief than partial resurfacing.

Section Summary: Partial Hip Resurfacing

The literature on partial hip surfacing for osteonecrosis includes a comparative study. There is an increase in poor outcomes with hemi-resurfacing compared with

THR, which is believed to be related to continued abrasion and possible misfit of

the femoral component against the native acetabular cartilage. Therefore, for


younger patients who do not have contraindications for the MoM prosthesis, THR

(femoral and acetabular implant) would be preferred over a femoral component

alone. Hemi-resurfacing would be appropriate in patients with osteonecrosis who have contraindications for a MoM prosthesis.

Summary of Evidence

For individuals who have an indication for hip replacement who would outlive a traditional prosthesis and have no contraindication for hip resurfacing who receive

a MoM THR device or a partial hip resurfacing device, the evidence includes 2

RCTs, numerous large observational studies, large registry studies, and systematic

reviews. Relevant outcomes are symptoms, change in disease status, functional outcomes, health status measures, quality of life, and treatment-related morbidity.

The efficacy of THR performed with current techniques is similar to that for THA

over the short-to-medium term, and THR may permit easier conversion to a THA

for younger patients expected to outlive their prosthesis. Based on potential ease of revision of THR compared with THA, current evidence supports conclusions that

hip resurfacing presents a reasonable alternative for active patients who are

considered too young for THA—when performed by surgeons experienced in the

technique. The literature on adverse events (eg, metallosis, pseudotumor

formation, implant failure) is evolving as longer follow-up becomes available. Due to the uncertain risk with MoM implants, the risk-benefit ratio needs to be

considered carefully on an individual basis. In addition, emerging evidence has

suggested an increased risk of failure in women, possibly due to smaller implant

size. Therefore, these factors should also be considered in the overall patient evaluation for THR, and patients should make an informed choice with their

treating physicians. The evidence is sufficient to determine that the technology

results in a meaningful improvement in the net health outcome.


traditional prosthesis and have no contraindication for hip resurfacing who receive,

the evidence includes 2 RCTs, numerous large observational studies, large registry

studies, and systematic reviews. Relevant outcomes are symptoms, change in

disease status, functional outcomes, health status measures, quality of life, and treatment-related morbidity. Therefore, these factors should also be considered in

the overall patient evaluation for THR, and patients should make an informed

choice with their treating physicians. The evidence is sufficient to determine that

the technology results in a meaningful improvement in the net health outcome.

Supplemental Information

Clinical Input From Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may

collaborate with and make recommendations during this process, through the

provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or

academic medical centers, unless otherwise noted.


In response to requests, input was received from 1 physician specialty society and

1 academic medical center while this policy was under review in 2013. Input was

mixed, although both reviewers agreed that evidence is not sufficient to conclude that the potential for harm with metal-on-metal hip resurfacing outweighs the

benefit for all patients. One reviewer noted that current cross-linked polyethylene

total hip components may last 20 to 30 years, limiting the number of patients who

would outlive a total hip prosthesis and be considered an appropriate candidate for total hip resurfacing.

Practice Guidelines and Position Statements

Hip Society

The Hip Society published an algorithmic approach to the diagnosis and

management of metal-on-metal (MoM) arthroplasty (total hip arthroplasty [THA],

total hip resurfacing [THR]) in 2012.36 The review indicated that adverse local tissue reactions to metal debris are escalating and that all arthroplasty patients

returning for follow-up should be queried for pain, discomfort, or compromise of

function. Symptomatic patients should be evaluated for all intra-articular and

extra-articular causes of pain, including aseptic loosening, sepsis, component

malposition, or fluid collections and/or masses about the hip. The Hip Society stated that there is still a role for MoM resurfacing arthroplasty in select patients

groups. The ideal candidate is a man younger than age 55 with osteoarthritis and

a femoral head size larger than 50 mm. Another relative indication is the need or

desire to return to a very high activity level at work or in recreation. Contraindications to MoM resurfacing include known or suspected metal

sensitivity; moderate or worse renal function; women who may become pregnant;

osteoporosis; large cysts; and avascular necrosis more than 50%.

California Technology Assessment Forum

In 2011, the California Technology Assessment Forum concluded there was no

evidence that the potential benefits of hip resurfacing outweighed the potential

risks.37 Revision rates appeared to be higher in patients receiving THR procedures

than in those receiving THA, which is of particular importance because the THR procedure targets young people. This risk may be particularly high in women. In

addition, the elevated levels of metal ions were concerning. Although the clinical

significance of these elevated ion levels is still uncertain, they are implicated in the

development of aseptic lymphocytic vasculitisassociated lesions, often seen in

aseptic failure of THR. Pseudotumors appear to be a more severe manifestation of

aseptic lymphocytic vasculitisassociated lesions. It was recommended that MoM

hip resurfacing using the Birmingham Hip Resurfacing, Cormet 2000, or Conserve

Plus devices did not meet California Technology Assessment Forum criteria for safety, efficacy, or improvement in health outcomes for patients as an alternative

to THA.

American Academy of Orthopaedic Surgeons

In 2010, the American Academy of Orthopaedic Surgeons published a technology overview on MoM hip resurfacing.38 To compare revision rates between MoM hip

resurfacing and THA, the Academy analyzed 3 joint registries, which indicated that


patients who received THR were at greater risk for revision than patients who

received THA. One registry suggested that younger men may have a lower

revision rate after THR than THA, although the available data were not found to clearly establish an advantage for this subgroup. There was no conclusive evidence

on predictors of successful or unsuccessful outcomes.

In 2011, the Academy provided a technology overview of modern MoM hip implants (both THA and THR).5 This document did not recommend for or against

use of MoM hip implants.

National Institute for Health and Care Excellence In 2014, the National Institute for Health and Care Excellence (NICE) updated its

guidance on THA and THR for end-stage arthritis of the hip.39 NICE concluded that

both THA and THR were options for treating end-stage arthritis of the hip,

although clinicians may be more likely to offer resurfacing arthroplasty to men than to women because of higher revision rates observed in women. NICE

concluded that THA was more effective and less costly than THR in all analyses,

that the revision rate was the most important key driver of costs and quality-

adjusted life years, and that, because the predicted revision rate of THA was less

than 5% at 10 years in the population for whom both THA and THR were suitable, the revision rate standard for THR should be the same as that for THA. NICE

recommended specific prostheses for THA and THR only if the prostheses have

revision rates of 5% or less at 10 years.

U.S. Preventive Services Task Force Recommendations

Not applicable.

Medicare National Coverage There is no national coverage determination. In the absence of a national coverage

determination, coverage decisions are left to the discretion of local Medicare

carriers.

Ongoing and Unpublished Clinical Trials A search of ClinicalTrials.gov in April 2018 did not identify any ongoing or

unpublished trials that would likely influence this review.

References 1. Blue Cross and Blue Shield Association Technology Evaluation Center. Metal-on-metal total hip

resurfacing. TEC Assessments. 2007;Vol 22:Tab 3. 2. Vendittoli PA, Lavigne M, Roy AG, et al. A prospective randomized clinical trial comparing

metal-on-metal total hip arthroplasty and metal-on-metal total hip resurfacing in patients less than 65 years old. Hip Int. Jan 2006;16(Suppl 4):73-81. PMID 19219833

3. Food and Drug Administration. P040033: Birmingham Hip Resurfacing (BHR) System. 2006; http://www.accessdata.fda.gov/cdrh_docs/pdf4/p040033a.pdf. Accessed February 22, 2018.

4. Australian Orthopedic Association. National Joint Replacement Registry Annual Report. Adelaide, Australia: AOA; 2006.

5. American Academy of Orthopaedic Surgeons (AAOS). Modern metal-on-metal hip implants: A

technology overview. 2011; http://www.aaos.org/news/aaosnow/jan12/cover1.asp. Accessed February 22, 2018.


6. Food and Drug Administration (FDA). Metal-on-Metal Hip Implants: FDA Safety Communication. 2013; http://wayback.archive-it.org/7993/20170722215742/https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm335775.htm. Accessed March 26, 2018.

7. Nunley RM, Della Valle CJ, Barrack RL. Is patient selection important for hip resurfacing? Clin Orthop Relat Res. Jan 2009;467(1):56-65. PMID 18941859

8. Marker DR, Strimbu K, McGrath MS, et al. Resurfacing versus conventional total hip arthroplasty - review of comparative clinical and basic science studies. Bull NYU Hosp Jt Dis. Jul 2009;67(2):120-127. PMID 19583538

9. Jiang Y, Zhang K, Die J, et al. A systematic review of modern metal-on-metal total hip resurfacing vs standard total hip arthroplasty in active young patients. J Arthroplasty. Apr 2011;26(3):419-426. PMID 20851564

10. Quesada MJ, Marker DR, Mont MA. Metal-on-metal hip resurfacing: advantages and disadvantages. J Arthroplasty. Oct 2008;23(7 Suppl):69-73. PMID 18922377

11. Haddad FS, Konan S, Tahmassebi J. A prospective comparative study of cementless total hip arthroplasty and hip resurfacing in patients under the age of 55 years: a ten-year follow-up. Bone Joint J. May 2015;97-B(5):617-622. PMID 25922454

12. Mont MA, Seyler TM, Ragland PS, et al. Gait analysis of patients with resurfacing hip arthroplasty compared with hip osteoarthritis and standard total hip arthroplasty. J

Arthroplasty. Jan 2007;22(1):100-108. PMID 17197316 13. Lavigne M, Therrien M, Nantel J, et al. The John Charnley Award: The functional outcome of hip

resurfacing and large-head THA is the same: a randomized, double-blind study. Clin Orthop Relat Res. Feb 2010;468(2):326-336. PMID 19543863

14. Garbuz DS, Tanzer M, Greidanus NV, et al. The John Charnley Award: Metal-on-metal hip resurfacing versus large-diameter head metal-on-metal total hip arthroplasty: a randomized clinical trial. Clin Orthop Relat Res. Feb 2010;468(2):318-325. PMID 19697090

15. Azam MQ, McMahon S, Hawdon G, et al. Survivorship and clinical outcome of Birmingham hip resurfacing: a minimum ten years' follow-up. Int Orthop. Jan 2016;40(1):1-7. PMID 25820838

16. Daniel J, Pradhan C, Ziaee H, et al. Results of Birmingham hip resurfacing at 12 to 15 years: a single-surgeon series. Bone Joint J. Oct 2014;96-B(10):1298-1306. PMID 25274912

17. Murray DW, Grammatopoulos G, Pandit H, et al. The ten-year survival of the Birmingham hip resurfacing: an independent series. J Bone Joint Surg Br. Sep 2012;94(9):1180-1186. PMID 22933488

18. Matharu GS, McBryde CW, Pynsent WB, et al. The outcome of the Birmingham Hip Resurfacing in patients aged < 50 years up to 14 years post-operatively. Bone Joint J. Sep 2013;95-B(9):1172-1177. PMID 23997127

19. Pailhe R, Matharu GS, Sharma A, et al. Survival and functional outcome of the Birmingham Hip Resurfacing system in patients aged 65 and older at up to ten years of follow-up. Int Orthop. Jun 2014;38(6):1139-1145. PMID 24370976

20. Amstutz HC, Le Duff MJ, Campbell PA, et al. Clinical and radiographic results of metal-on-metal

hip resurfacing with a minimum ten-year follow-up. J Bone Joint Surg Am. Nov 2010;92(16):2663-2671. PMID 21084576

21. Kim PR, Beaule PE, Laflamme GY, et al. Causes of early failure in a multicenter clinical trial of hip resurfacing. J Arthroplasty. Sep 2008;23(6 Suppl 1):44-49. PMID 18722302

22. Nunley RM, Zhu J, Brooks PJ, et al. The learning curve for adopting hip resurfacing among hip specialists. Clin Orthop Relat Res. Feb 2010;468(2):382-391. PMID 19779950

23. Gross TP, Liu F, Webb LA. Clinical outcome of the metal-on-metal hybrid Corin Cormet 2000 Hip

Resurfacing System: an up to 11-year follow-up study. J Arthroplasty. Apr 2012;27(4):533-538 e531. PMID 21908168

24. McGrath MS, Marker DR, Seyler TM, et al. Surface replacement is comparable to primary total hip arthroplasty. Clin Orthop Relat Res. Jan 2009;467(1):94-100. PMID 18797977

25. Ball ST, Le Duff MJ, Amstutz HC. Early results of conversion of a failed femoral component in hip resurfacing arthroplasty. J Bone Joint Surg Am. Apr 2007;89(4):735-741. PMID 17403794

26. de Steiger RN, Miller LN, Prosser GH, et al. Poor outcome of revised resurfacing hip arthroplasty. Acta Orthop. Feb 2010;81(1):72-76. PMID 20170416


27. Reito A, Puolakka T, Elo P, et al. Outcome of Birmingham hip resurfacing at ten years: role of routine whole blood metal ion measurements in screening for pseudotumours. Int Orthop. Nov 2014;38(11):2251-2257. PMID 25030963

28. Williams DH, Greidanus NV, Masri BA, et al. Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg Am. Dec 7 2011;93(23):2164-2171. PMID 22159851

29. Kwon YM, Ostlere SJ, McLardy-Smith P, et al. "Asymptomatic" pseudotumors after metal-on-metal hip resurfacing arthroplasty: prevalence and metal ion study. J Arthroplasty. Jun 2011;26(4):511-518. PMID 20591612

30. Steffen RT, Pandit HP, Palan J, et al. The five-year results of the Birmingham Hip Resurfacing arthroplasty: an independent series. J Bone Joint Surg Br. Apr 2008;90(4):436-441. PMID 18378915

31. Ollivere B, Darrah C, Barker T, et al. Early clinical failure of the Birmingham metal-on-metal hip resurfacing is associated with metallosis and soft-tissue necrosis. J Bone Joint Surg Br. Aug 2009;91(8):1025-1030. PMID 19651828

32. Mont MA, Seyler TM, Ulrich SD, et al. Effect of changing indications and techniques on total hip resurfacing. Clin Orthop Relat Res. Dec 2007;465:63-70. PMID 17891034

33. Grecula MJ. Resurfacing arthroplasty in osteonecrosis of the hip. Orthop Clin North Am. Apr 2005;36(2):231-242, x. PMID 15833461

34. Stulberg BN, Fitts SM, Zadzilka JD, et al. Resurfacing arthroplasty for patients with osteonecrosis. Bull NYU Hosp Jt Dis. Jul 2009;67(2):138-141. PMID 19583542

35. Beaule PE, Amstutz HC, Le Duff M, et al. Surface arthroplasty for osteonecrosis of the hip: hemiresurfacing versus metal-on-metal hybrid resurfacing. J Arthroplasty. Dec 2004;19(8 Suppl 3):54-58. PMID 15578554

36. Lombardi AV, Jr., Barrack RL, Berend KR, et al. The Hip Society: algorithmic approach to diagnosis and management of metal-on-metal arthroplasty. J Bone Joint Surg Br. Nov

2012;94(11 Suppl A):14-18. PMID 23118373 37. California Technology Assessment Forum. Metal on Metal Hip Resurfacing as an Alternative to

Total Hip Arthroplasty: A Technology Assessment. 2011; http://icer-review.org/wp-content/uploads/2016/01/769_file_Hip_resurfacing_W.pdf. Accessed February 22, 2018.

38. McGrory B, Barrack R, Lachiewicz PF, et al. Modern metal-on-metal hip resurfacing. J Am Acad Orthop Surg. May 2010;18(5):306-314. PMID 20435881

39. National Institute for Health and Care Excellence (NICE). Total hip replacement and resurfacing

arthroplasty for end-stage arthritis of the hip [TA304]. 2014; https://www.nice.org.uk/guidance/ta304. Accessed February 22, 2018.

Billing Coding/Physician Documentation Information 27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement

(total hip arthroplasty), with or without autograft or allograft

27299 Unlisted procedure, pelvis or hip joint S2118 Metal-on-metal total hip resurfacing, including acetabular and femoral

components

ICD-10 Codes M16.10-

M16.9

Osteoarthritis of hip code range

M87.051-

M87.059

Idiopathic aseptic necrosis of femur

There is no specific CPT code for total hip resurfacing. It will most likely be coded

as 27130 [arthroplasty, acetabular and proximal femoral prosthetic replacement

(total hip replacement), with or without autograft or allograft] or 27299 (unlisted

procedure, pelvis or hip joint).


Additional Policy Key Words N/A

Policy Implementation/Update Information 10/1/06 New policy; considered investigational.

5/1/07 Policy statement updated: metal-on-metal total hip resurfacing with an

FDA-approved device system now may be considered medically necessary as an alternative to total hip replacement in patients who are

candidates for total hip replacement and who are likely to outlive a

traditional prosthesis. All other types and applications of total hip

resurfacing remain investigational. 5/1/08 No policy statement changes. The Cormet Hip Resurfacing System

received FDA approval in July 2007.

5/1/09 No policy statement changes.

5/1/10 Policy statement added for partial resurfacing; considered medically

necessary in specific conditions. Policy title updated to remove “Total” from the title.



7/1/12 No policy statement changes. 7/1/13 No policy statement changes.

7/1/14 Information added to Considerations on patient selection. No policy

statement changes.

7/1/15 No policy statement changes. 7/1/16 No policy statement changes.



State and Federal mandates and health plan contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The medical policies contained herein are for informational purposes. The medical policies do not constitute medical advice or medical care. Treating health

care providers are independent contractors and are neither employees nor agents Blue KC and are solely responsible for diagnosis, treatment and medical advice. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, photocopying, or otherwise, without permission from Blue KC.


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